00080166 CITY OF CUPERTINO
ButLDING DIVISIONpERMIT CONTRACTOR INFORMATION:
HUILDINGADDRESS! r - FERMI"1'NO,
gpicintsi Au Hnt ,�ATFR INC 080166•
OWNER'S NAME i t - I APPLICAI ION SUB DATE'
cQ11Z10
I( ..IN iS SANITARY NO. CONTROL NO.
�ZZ ARCHITECTIENGINEER: HUILDING PERMIT INFO
U— BLDG ELECT PLUMB MUCH
Z S n Z LICENSEDCONTRAC'IOR'S DECI.ARA'I'ION, 1 .106 Description +
O I hemby aflina that l am licensed under previsions of Chapter 4(commend^g P
p:a•m wish Section 70(X4of Division 34lhe Business and Prefec,i...Cods.aalmyliceme' -
" in full force and eReet.
Sod uemacwa. N WATER HEATER
,3 LL l- , Dlna Commtaor `•
ARCfIIll be,.adasCLARA'nON - -
g 1 understand my plain shall be used ro public DECLARATION
Ns
�Y
.�p O Licensed Pimessi and v
°� OWNER-HUH-DERUGCLARAI'ION
, 't
m�"II hereby 11 that Jain exempt front the C t l L I for the
C S2F a fell g .(See,,..7011 5 Bu: d Prof Cod A y Ty aunty - -
. r'0 wtA
which , permit 1 t,alual,onamove.d I h p, y.t cmtn .
3 pr 1 t 1 II ..l' tf ), t t fl 4 dstatement
Ihactl II uol,0 Ir I the Cannowun,License Law(Chapter 9 Sq. Ft. Floor Area. Q Valuation
(co toting with Seen..71X111)al Diviv n 3 of the Bus nec,and I nhRssmm Code) .
or that he is exempt, mfhee m and the basis for the alleged exemption.Any violated -
of Scaion 7031.5 by tiny applicant for n pc..it subject the applicant to a civil penalty -
ef net mare than r a hundred dollars($500). APN Number - O cupancy Type
111,av uwncnd the lropenri o,Or,employees win w.gm as thane sale compensation.' '
will do the work,and the swcture is not intended or offered for sale(See:7014.
Business and Pmmmsions Cede:The Contractor's License law Wes not apply to act Required Inspections
o"o.r of property Who builds or itnprovcx Blumeon,and who does such week himself
aushln.owtbra,kycaI.PlPvicedLot,nchiamovatnams.arent,liutaudedO` 502 - FINAL-' PLUMBING ENERGY
ultercal lot sale.If,however,the funding or improvement is.sold within one year of
empletion.the owner-bunderwillhavetheburdenofprovingmmnedidnmhuudor 506 — GAS-TEST
improve for pialo's of sale.)..
111.a,owner of the properly,am exclusively rantm�tins with Licensed eonnacton m 507, - •'F I NRI_ PLUMBING
construct the proper,(ties.7104,liminess and'Profess aas Code
p'fbe Comranmts
License law docs nn1 apply nh un owner of initially who huilAs or inhproves nemnn,
and%he contracts for such projects with a contractnr(.$)licensed pursuant to the
Commnors license Law. -
ElIantexemptunderSer. ,If'&PC for this mmnt
Owner 'Date
WORKER'S COMPENSATION DECLARATION
1 hereby afinn under penalty of perjury one of the following dednmtiom:
.1 I have,and will tnwnti in a Cert tate(it G;noot .h sdcinsttre for Worker's •.
Compsnsntion, as provided for by Section 370 of the Labor Glide, for the
performance of the work for which this pemdt is issued '
-°I huge and will maintain Worker'.Compenantinn nsur..¢c,as oc sal by Suchen -
3700 of the Lauer Code,for tiro periormame of the work for which this permit Is '
orad.My Worker's Compen^tion Insurance carrier and Policy number am:
' Carrier. Policy NO,,:
CIR'UpICAT10N OP EXEMVUON FROM WORKERS'
• COMPENSATION INSURANCE ,
(This section need not be complete if the permit is ho one hundred dollars -.
ISHXB er less.)
I certify 111.1 is the perliarran c.1 the work for which this permit Is Issued.I
shall not employ any penan in any manner so as to becunm subject to the Warken'- + a
Compemmm.Laws of Califnmia.Dae
Applicant
NOTICB TO APPLICANT:IL ipler making this Cenific,de of Exemption,you should ,
bec or subject to the WnaLet,Cnapcealion pn+visimhs cadre Lobar Cede,you taint
Q O fothwith comply with such provisions or this permit shall be deemed revoked.
,Z
,"'� 4 CONSTRUCTION LENDING AGENCY
� ' I hereby affirm that them is a convention lending agency for the performance -
W of he work for which this permit is issued(Stu.3097;Civ.C.) -
L (:] Lender's Name .
u. Z Lender's Address
V I ceNfy thin I have and this a,dicatia 0Iainemte Wet rte above inli,nallma is
Lr+ [�. correct.I agree to comply with all my and team,nedinmaex land stem laws relating,
Q [). to building construction,and hereby interim representatives of this city to enter area
the a awn-mentioned property for inspection purposes. -
[r 0. (We).gmc cosave,indemnifyind keep haimless the City of Clpamers,
Zn liabilities,judgments colts and expenses which may in any way amme against said
t� Cay In conseyuerce of the gmming of this Deme. )APPLICANT
SOURCE EGUWTIONSNDS AND WILL COMPLY WD'II ALL NON-POINT Issued by: Date
Signature of APFlicanUConttactor - Dae Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE a
Will the appdcnm or furom funding occup:mt store or hamue haauraous maedal "type of Roof . .
as derated by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Cole.Section 25532(al" y ,
°Yes 0 N - h. h
- All roofs shall be inspected prior to any roofing material being installed.
Will Weuppliar,orLoanal.ailnngree",alllie brim, seat... avianwhieh If.a roof is installed withoht first obtainingan inspection-I a gree to remove
mit lhamnl.m air eomnmibula,asdefined by the Buy Amu Air Quality Manng6read P }
omen all new materials for, pP PY inspection. A Itcant,understands and will comply with
Pf °Yep °N" all non-point source regulations.; .
1 have mad the In,lini ....torics,ram anent,tmdcr Ch.pler 695 of the
California health&Safely Cod�Scctinns 25511.5,25533 and 25534.1 understand that -
if the building does not embroil have a tenant.that it is my malleability m notify the
occupant of rte"Of....art,whichh most be met prier to issuance of a Ccm,me.1 -
Occupancy . .
Signature of Applicant Date
Owae,.1 anthenmr!agent ,.,a - All roof coverings to be Class+'B"or better
OFFICE